How Medicare works with Insurance Plans

There are several situations individuals may find themselves in when Medicare starts and they are also enrolled in or soon to be enrolled in an insurance plan.

Typical insurance plans:  Medicare Supplement, Medicare Advantage and employer group plans.  Original Medicare A and B coverage works differently for each policy type.

Medicare Supplement – When a person starts Medicare, typically at age 65 and enrolls in a Medicare Supplement (Medigap) policy, the arrangement is; Original Medicare is considered “primary” coverage and the Medicare Supplement is “secondary.” What this means is, the primary coverage pays first.  For example when a doctor or hospital submits the medical claim, it goes directly to the primary coverage first.  The Medicare Supplement, or “secondary” coverage is then notified and pays their portion.

Also, regarding to access to care, since Medicare is “primary” in this example, you follow the Medicare rules with which doctors and hospitals you can use.  Medicare allows you to see any Medicare approved doctor anywhere in the U.S.  No networks to fuss with.

Medicare Advantage Plans which are mostly HMO’s and PPO’s, on the other hand are ‘primary’ coverage and Medicare taking a back seat and not providing much of anything.  As the Advantage plan is primary coverage, you must also follow the primary plan rules regarding networks of doctors and hospitals. If it is a HMO style plan, you will need to choose a primary care physician who will organize your care. A PPO style plan will have a network of doctors, specialists and hospitals you are free to move freely within.  You can see doctors outside of the PPO network, although your costs will go up significantly.

Employer Plans with 20 or more employees will pay first (primary insurance) with medicare paying second.  For amounts not payed by the group health plan, your doctor can submit the claim to Medicare and Medicare will pay based on what the group health carrier paid, and what the group health plan allowed.  Employer groups under 20 employees, Medicare will be your “primary” coverage and pay first.

To learn more about how Medicare coordinates with different types of insurance plans please feel free to call me or email and I’ll be happy to answer all of your questions.

Below are information and recourse links for; Medicare Supplement, Medicare Advantage and Part D Rx plans.

Open Enrollment Guidelines:

When enrolling in a Medicare Supplement, Medicare Advantage or Medicare Part D Rx policy, there are two routes a person usually takes.

  1. Either the enrollment is guaranteed based on a number of situations such as being new to Medicare or exiting an employer plan, along with many others.
  2. Or, the applicant must answer all medical history questions along with current and past doctors and prescriptions taken.  The company will then review the questions answered and base their approval or decline based on your health status.

The Medicare Supplement industry has certain rules and regulations pertaining to “guarantee-issue” situations and “open-enrollment.”

Medicare Advantage enrollment is typically during the Annual Open Enrollment Period which runs annually from October 15 through December 7.  All changes take place on January 1 for the following year.

If you are new to Medicare, you have an open enrollment for each of these policies: Medicare Supplement open enrollment is 6 months from the date your Medicare Part B starts.  Medicare Advantage is 3 months and Medicare Part D Rx plans are also 3 month.

Here are some of the Open-Enrollment rules and guidelines:  Click Here

John Conner

John Conner

Medicare Plan Options ... Medicare Supplement, Medicare Advantage, Medicare Part D Rx